Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study

Successful Empirical Treatment of Suspected Spinal Tuberculosis: A Case Report

Spinal tuberculosis is an uncommon extrapulmonary manifestation of tuberculosis infection, known as a great masquerade that often mimics other pathologies, such as pyogenic and non-pyogenic infection, bone metastasis, haematological malignancy, and metabolic bone disease. It presents great challenges in establishing a diagnosis, deciding on treatment, and monitoring the response to treatment. A tissue-proven diagnosis is the cornerstone of a definitive diagnosis before initiating medical antitubercular therapy, leading to successful treatment. Here, we present a distinct and rare instance of spinal tuberculosis with an atypical presentation of upper thoracic myelopathy. It involved the cervicothoracic junction, exhibiting minimal axial symptoms but intensive destruction of the affected levels radiologically, along with an incomplete neurological deficit and the possibility of catastrophic neurological complications. The ultimate distinctiveness of this case lies in the diagnostic challenge it posed. Despite undergoing three separate tissue biopsies, tuberculosis infection could not be established, as all results returned negative for cellular, molecular, and histopathological markers, leading to a delay in initiating empirical medical therapy. Nonetheless, the patient responded well to empirical antitubercular therapy, resulting in favourable outcomes. To the best of our knowledge, a case of spinal tuberculosis with numerous negative tissue diagnoses has not been previously reported.

Predictive Value of Vertebral Bone Destruction Classification Based on Computed Tomography in Diagnosing on Adult Spinal Tuberculosis

OBJECTIVE

Although magnetic resonance imaging (MRI) is well-established for evaluation of spinal tuberculosis (TB), the importance of computed tomography (CT) should not be overlooked. The purpose of this study was to determine the characteristics of spinal TB and the relationship between spinal TB and the bone lesion pattern seen on three-dimensional CT images.

METHODS

One hundred and sixty-one subjects were divided into a TB-positive group and a TB-negative group based on laboratory (X-pert mycobacterium tuberculosis/ rifampin) results and then subdivided further according to whether the bone lesion pattern seen on three-dimensional CT images was fragmentary, osteolytic, sclerotic, or had no evidence of bone destruction. The diagnostic value of the bone lesion pattern was compared between the TB-positive and TB-negative groups.

RESULTS

Ninety-nine of the 161 patients were TB-positive and 62 were TB-negative. Fifty-six (34.8%) of the 161 patients had fragmentary/osteolytic lesions, seventy-four (45.9%) had absolute osteolytic lesions, 13 (8.1%) had osteosclerotic lesions, and 18 (11.2%) had no evidence of bone destruction. The fragmentary/osteolytic lesion pattern was strongly predictive of spinal TB (odds ratio 3.33), and when combined with 3 MRI findings (thin abscess wall, more than one half of the vertebral body destroyed, and subligamentous spread) had an even stronger diagnostic value (odds ratio 15.58).

CONCLUSIONS

The absolute osteolytic pattern was the most common of the bone lesion patterns. The fragmentary/osteolytic pattern is highly suggestive of spinal TB, especially when combined with MRI findings of a thin abscess wall, destruction of more than one half of the vertebral body, and subligamentous spread.

Active tuberculosis of spine: Current updates

Background

Spinal tuberculosis (TB) is the most common extrapulmonary form of tuberculosis. In both developing and developed countries, TB has been on the rising trend due to factors such as increasing HIV coinfection, multidrug resistance of the organism, and global migration. Spinal TB, which most often affects the lower thoracic and thoracolumbar area, accounts for 50% of all musculoskeletal tuberculosis.

Methods

Using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed, a systematic computerized literature search was performed. Analyses of studies published within the past 10 years were conducted. The searches were performed using Medical Subject Headings terms, with "spinal tuberculosis," "diagnosis," "epidemiology," and "etiology","management," "surgery," and "therapy" as subheadings.

Results

Progressive collapse, kyphosis, and neurological deficiency are hallmarks of the disease because of its destructive effect on the intervertebral disc and adjacent vertebral bodies. The condition may be identified using laboratory testing and distinctive imaging features, but the gold standard for diagnosis is tissue diagnosis using cultures, histology, and polymerase chain reaction. Uncomplicated spinal TB is today a medical condition that can be adequately treated by multidrug ambulatory chemotherapy. Surgery is reserved for individuals who have instability, neurological impairment, and deformity correction. Debridement, deformity correction, and stable fusion are the cornerstones of surgical treatment.

Conclusions

Clinical results for the treatment of spinal TB are generally satisfactory when the disease is identified and treated early. However, the major health issue and the biggest obstacle in achieving the goals of the "End TB strategy" is the recent rise in the emergence of drug resistance. Hence strict vigilance and patient perseverance in the completion of the treatment is the main need of the hour.

Cervical Pott's Disease Presenting As Quadriplegia in a Young Patient: A Case Report

Cervical Pott's disease, a form of spinal tuberculosis (TB), is a significant concern in low- and middle-income countries (LMICs). Early detection and treatment are critical to preventing complications like vertebral collapse. Clinical and radiological features of cervical Pott's disease can resemble other spinal conditions, posing diagnostic challenges. We present a case of a 28-year-old female who initially presented with quadriplegia, cervical instability, and high-grade fever. Through multidisciplinary collaboration and prompt intervention, the patient was diagnosed with cord compression syndrome secondary to a cervical abscess and probable cervical Pott's disease. Anti-tuberculosis treatment (ATT) and steroids were initiated, leading to significant improvement in symptoms and disease resolution. In summary, this case underscores the diagnostic challenge of cervical Pott's disease and the importance of imaging in TB diagnosis in resource-limited settings. The positive treatment response emphasizes early intervention's significance.

Delphi-Based Survey for Surgical Indications in Biopsy Proven Active Adult Spinal Tuberculosis

STUDY DESIGN

Delphi survey.

OBJECTIVES

To obtain an expert consensus on various dilemmas in the surgical treatment of adult spinal tuberculosis (TB) patients.

METHODS

Stage I included a literature review, stage II the identification of 40 Key Opinion leaders (KOLs) and a set of 46 questions, stage III included analysis of 3 rounds of the Delphi survey, and stage IV had final analysis and recommendations. For each question, the level of agreement needed to reach a consensus was set at greater than or equal to 70.0%.

RESULTS

The first and second Delphi survey rounds received 62 and 58 responses, respectively, with 16 questions having more than 70% and two questions having 100% agreement in the first stage. The second stage saw a 70% agreement on six questions. Thus, a consensus was obtained on 22 questions. The recommendations that emerged were as follows: neurodeficit with corresponding radiology and neurological deficit appearing/deteriorating while on anti-tubercular chemotherapy(ATT) are absolute indications for surgery, duration of ATT before neurological deterioration need not be considered, epidural abscess does not need decompression unless concordant clinical neurological findings are present, pain not responding to medical management is not a surgical indication, active pulmonary TB, drug-resistant TB, and tubercular sacroiliitis are not considered as surgical indications, and hemoglobin and other health markers have little contribution to surgical indications.

CONCLUSION

In order to resolve several conundrums in the surgical treatment of adult spinal TB, this Delphi survey is the first to achieve a national consensus from spine experts. The final recommendations cover the serological, radiographic, and clinical aspects of spinal TB.

Non-contiguous Rare Presentation of Spinal Tuberculosis: A Case Report

Spinal tuberculosis (TB), also known as Pott's disease, is a severe form of extrapulmonary TB that affects the vertebral bodies and intervertebral discs. While the typical presentation involves the contiguous involvement of multiple vertebrae, atypical forms, such as non-contiguous multilevel spinal TB (NMLST), can occur. However, diagnosing spinal TB poses challenges due to its gradual onset, nonspecific symptoms, and varying imaging results. The timely diagnosis and treatment of spinal TB are critical to prevent serious consequences, including vertebral damage, irreversible neurological impairment, or even death. In this report, we present the case of a 58-year-old South Asian female who presented with several months of back pain, fatigue, and weight loss. Despite initially negative TB test results, spinal magnetic resonance imaging (MRI) raised suspicion of NMLST, which was later confirmed by bone biopsy. This case highlights the complexities of diagnosing and managing atypical spinal TB presentations while discussing the case findings and reviewing relevant research.

Surgical management and clinical outcome of cervical, thoracic and thoracolumbar spinal tuberculosis in a middle-European adult population

Spinal tuberculosis is due to globalization no longer a disease limited to developing nations. It remains in Germany a rarity and still a difficult diagnosis. Here we analyzed patients with spinal tuberculosis treated at our neurosurgical department. According to the infected anatomic segment, patients were assigned in one of three groups. Surgery was performed when neurological deficit due to mechanical compression, deformity, instability, severe pain, necrotic bone or failure to respond to anti-tuberculous treatment were observed. We identified 34 patients with spinal tuberculosis who underwent surgical treatment. In the cervical spinal tuberculosis group, there were 15 cases (46.9%) In most cases treatment consisted of spinal instrumentation. In the thoracic group, 10 cases (29.4%) were observed. The treatment was performed by dorsolateral spinal instrumentation. For the thoracolumbar group, 9 cases (26.4%) were observed. In most cases dorsolateral spinal instrumentation was performed. One patient in the first group and one patient in the third group relapsed after operation. A second surgery was necessary. Patients with chronic back pain, immigration background and/or neurological deficit spinal TB should be considered as a differential diagnosis. Combined surgical intervention and medical treatment is associated with a favorable outcome.

Spinal Tuberculosis within the Vertebral Arch Mimicking a Malignant Tumor: Case Report

BACKGROUND

 Spinal tuberculosis is a manifestation of extrapulmonary tuberculosis. The incidence of tuberculosis is low in high-income countries; however, globally, it still remains one of the most frequent fatal infectious diseases. Because of its rarity in developed countries, spinal tuberculosis can be mistaken for malignant tumors of the spine, especially in case of an atypical radiologic manifestation and without pulmonary affection.

METHODS

 We present the case of a 39-year-old man from South India with quickly progressing gait disturbance and hypesthesia below the Th10 level. Magnetic resonance imaging revealed an osteolytic lesion of the vertebral arch Th2 with central necrosis and compression of the spinal cord altogether highly suspicious for spinal metastasis.

RESULTS

 After surgical removal of the mass by laminectomy, the patient regained normal neurologic function. Histology revealed a severe granulomatous inflammation and DNAhybridization of polymerase chain reaction (PCR) products detected Mycobacterium tuberculosis-specific DNA in the sample. Biopsy of an enlarged hilar lymphnode allowed us to obtain material to successfully perform a drug resistance test to start specific antimicrobial therapy.

CONCLUSION

 Spinal tuberculosis, even with atypical radiologic appearance, has to be considered a differential diagnosis in patients with provenance from endemic countries. A multidisciplinary diagnostic approach helps perform antimicrobial susceptibility testing to avoid delaying the start of antibiotic therapy.

A case of spinal tuberculosis presenting with cauda equina syndrome

Tuberculosis (TB) of the central nervous system accounts for only 1% of all cases of TB but 50% of these occur in the spine. Common clinical manifestations of spinal TB include fever, weight loss, back pain, lower limb weakness (either upper or lower motor neuron), and skeletal deformities such as kyphosis or gibbus. Infective pathology caused by Mycobacterium tuberculosis with epidural collection can present as acute cauda equina syndrome. Here, we describe a 28-year-old female patient who presented with low back pain and ascending weakness of both lower limbs (Medical Research Council grade 4/5 with absent ankle reflex) for 2 months with sudden-onset loss of bladder and bowel control for 1 day without any localized spinal tenderness, swelling, or discharging sinus in the back. Magnetic resonance imaging (MRI) spine was suggestive of an intraosseous collection with spondylodiscitis at the L4 level vertebral level. MRI can help identify the involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and the presence of vertebral column deformities making it a sensitive tool for the detection of spinal TB. Antituberculous treatment remains the cornerstone of treatment. Surgery is required in selected cases, for example, large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. A combined intervention of laminectomy with drainage of the collection with antitubercular therapy after microbiological evidence helped in the resolution of the patient's condition. Early diagnosis and appropriate treatment generally result in a good prognosis.

Recovery of Long Standing Neurological Deficit in Pediatric Dorsal Spinal Tuberculosis: A Single Center Experience of 13 Cases

STUDY DESIGN

Retrospective analysis of case series.

OBJECTIVE

The aim is to study the recovery of neurological deficit in pediatric spinal tuberculosis cases presenting to us more than 6 months after onset of motor weakness in lower limbs.

METHODS

This is a retrospective analysis of 13 consecutive patients of pediatric spinal tuberculosis presenting to us at least 6 months after the onset of neurologic deficit. All these patients underwent surgical intervention at our center and their neurological recovery was noted in terms of improvement in Frankel grading and spasticity improvement by modified Ashworth scale. All the patients were followed up to at least 18 months post op and final neurologic status was assessed at that time.

RESULTS

The mean age of the patients at presentation was 8.5 years. The mean duration of neurologic deficit at the time of presentation was 10.23 months (6-24 months). Seven patients had a Frankel grade B at presentation out of which 6 improved to Frankel grade D and one improved to Frankel C at final follow up. Out of the other 3 patients with Frankel A at presentation, 2 improved to Frankel grade D and 1 to Frankel grade C. The remaining 3 patients presented with Frankel grade C at presentation, 2 improved to Frankel D and one improved to Frankel E at the time of final follow up.

CONCLUSION

Neurologic recovery in patients with neurological deficit is possible even in cases of long standing deficit more than 6 months and in some cases upto 24 months as shown in our study.

Comparative efficacy of traditional conservative treatment and CT-guided local chemotherapy for mild spinal tuberculosis

Background

There are considerable differences in the treatment strategy for spinal tuberculosis, including conservative or surgical procedures. Conservative treatment is always suitable for most patients. This study aimed to compare the clinical efficacy of traditional conservative treatment with CT-guided local chemotherapy strategy of mild spinal tuberculosis.

Methods

This research retrospectively analysed 120 patients with spinal tuberculosis between January 2005 and January 2016 according to the diagnostic criteria of mild spinal tuberculosis. In total, 89 patients underwent traditional conservative treatment, 31 underwent CT-guided local chemotherapy. Clinical outcome, laboratory indexes, and radiological results were analysed to provide a clinical basis for the choice of mild spinal tuberculosis treatment.

Results

All cases achieved a clinical cure with 24 to 50 months followed up. Cobb angle of the two groups spinal tuberculosis segments was 6.25 ± 3.1100B0, 5.69 ± 2.5800B0 before treatment and 12.36 ± 6.3100B0, 14.87 ± 7.2600B0 after treatment, respectively. The VAS scores were significantly decreased post-treatment. At the 1 month follow-up, the VAS scores and erythrocyte sedimentation rate (ESR) were significantly differences between the two groups. The efficacy in the CT-guided local chemotherapy (Group B) was better than the traditional conservative treatment (Group A). But from the 3 months follow-up to the last follow-up, the VAS scores and ESR was no significant differences between the two groups and the average ESR decreased to normal. There was no evident kyphosis, symptoms or neurological deficits at the final follow-up. The paravertebral abscesses had disappeared, with no significant progression of local kyphosis, significant absorption and clear lesion edges, pain relief and normal ESR in the two groups.

Conclusions

For mild spinal tuberculosis, traditional conservative treatment can achieve satisfactory results. The strategy combined with CT-guided local chemotherapy treatment is minimally invasive, beneficial for the drainage of paravertebral abscesses and pain relief.

Are we neglecting long-term effects of vertebral shortening on pulmonary function in spinal tuberculosis?

PURPOSE

In developing part of the world, it is common to see complete destruction of vertebral bodies in tuberculosis. Our study aims to assess the effect of spinal tuberculosis with vertebral shortening on pulmonary function.

METHODS

Fifty cases of spinal TB (14 males, 36 females) managed both operatively and non-operatively, who presented to tertiary care institute between years 2011 and 2016 were assessed. Vertebral height loss was assessed by spinal deformity index (SDI). All patients underwent pulmonary function testing using same equipment sitting in upright position.

RESULTS

Mean age was 27.9 years (27.9 ± 11.9). 11 patients with mean SDI of 2.7 ± 1.1 showed normal lung function. 36 patients showed restrictive pattern of which 12 were mild, 14 were moderate and 10 showed severe pattern with a mean SDI of 3.8 ± 1.2, 5.6 ± 1.3 and 6.1 ± 1.4, respectively. 3 cases showed obstructive pattern. As the apex of curve shifted proximally, FVC% reduced. Increase in SDI value was associated with a fall in the vital capacity and FEV₁. Increase in the kyphotic angle was associated with a deleterious effect on PFT results.

CONCLUSIONS

Risk stratification of pulmonary dysfunction resulting from vertebral body height loss due to kyphosis will emphasize the need for early detection of spinal tuberculosis before deformity occurs.

Pott's paraplegia and role of neuroimaging in resource limited setting: A case report and brief review of the literatures

BACKGROUND

Tuberculosis (TB) is the leading cause of morbidity and mortality in low and middle income countries (LMIC). Approximately 50% of cases of skeletal TB involve the spine. Failure to identify and treat these areas of involvement at an early stage may lead to serious complications such as vertebral collapse, spinal compression, and spinal deformity. The clinical and radiologic features of Pott's disease may mimic other spine diseases such as, metastatic lesions and other infectious etiologies, this is especially imperative in older patients.

CASE REPORT

We report a 60-year-old right handed male patient presented with back pain, paraparesis, and sensory symptoms 2 weeks duration. He has history of dry cough, fatigue, and reduced appetite, but no history of weight loss, fever, night sweat, and bowel/bladder incontinence. No contact history with TB patients. He has a borderline hypertension and diabetes mellitus. Serology for HIV was negative. Thoraco-lumbar magnetic resonance image (MRI) showed destruction of L2 and L3 vertebral body and the inter-vertebral disc; with T2 hyper and T1 hypointensity of the affected vertebral bodies. Probable tuberculous spondylitis with paraparesis was considered and the patient was initiated on antituberculous regimen and short course steroid therapy. After five months treatment, the patient showed significant clinical and radiological improvement.

CONCLUSION

In summary, the present case describes, a patient with Pott's paraplegia due to probable spine tuberculosis and showed significant clinical and radiological improvement following initiation of antituberculous drugs and short course of steroid; indicating the crucial role of imaging in the diagnosis of TB, especially in resource limited settings.

Pott Disease: A Tale of Two Cases

Tuberculosis is considered one of the great masqueraders alongside syphilis and vasculitis. Pott disease is recognized as a classic manifestation of tuberculosis, yet it stands as a rare infectious syndrome in regions with low tuberculosis disease burden. To illustrate the challenges of diagnosing Pott disease in these settings, we report two cases and offer a brief overview of management recommendations for vertebral osteomyelitis caused by Mycobacterium tuberculosis. Case one concerns an 81-year-old man with a remote history of incarceration who presented with altered mental status and new pleural effusions. Case two is a 49-year-old man with well-controlled HIV who was transferred to our institution after being found to have extensive destruction of L3-L5 vertebrae and bilateral iliopsoas abscesses on outpatient imaging. These stand as illustrative examples of low and high suspicion for tuberculosis, respectively, and both cases required complex diagnostic and management decisions.

Epidemiological Insights from 1,652 Patients with Spinal Tuberculosis Managed at a Single Center: A Retrospective Review of 5-Year Data

Study Design

Retrospective cohort.

Purpose

To report the demographic characteristics, clinico-radiological presentation, laboratory findings, and outcomes of "middlepath" treatment in patients with spinal tuberculosis from a single public healthcare facility in a developing country.

Overview of Literature

Tuberculosis is a global health problem that is endemic in developing countries and undergoing resurgence in developed ones. Spinal tuberculosis can cause disabling back pain, progressive deformity, and neurological involvement. However, there is a lack of large-scale epidemiological studies quantifying the size and severity of the problem of spinal tuberculosis.

Methods

Hospital records of spinal tuberculosis patients treated at a single center over a period of 5 years were retrospectively reviewed. A diagnosis of spinal tuberculosis was based on standard clinical, radiological, microbiological, and histopathological evidence. Patients were treated in accordance with the "middle-path" regimen; surgery was reserved for selective indications.

Results

A total of 1,652 patients were included. Their median age was 32.4 years, with 53% being male. Axial pain (98%) was the most common presenting symptom; 19% of patients had neurological deficit. Lumbar spine (37%) was the most common site of involvement, with a paradiscal pattern (82%) of involvement predominating. Multi-level involvement was seen in 19% of patients; skip lesions were noted in 2.8%. Transpedicular biopsy was performed in 667 patients; at least one tissue test was diagnostic of tuberculosis in 65% of patients. Forty-four patients had drug resistance to rifampicin. Surgery was required in 10.5% of patients. The "middle-path" regimen was associated with high compliance and significant improvements in pain (Visual Analog Scale score) and function (36-Item Short Form Health Survey).

Conclusions

Our findings confirm the widespread prevalence of spinal tuberculosis and describe various epidemiological characteristics of a large sample of spinal tuberculosis patients. Adoption of the "middle-path" regimen is associated with high compliance and favorable outcomes in spinal tuberculosis.

Application of Oblique Lateral Interbody Fusion in Treatment of Lumbar Spinal Tuberculosis in Adults

OBJECTIVE

The purpose of the present paper was to evaluate the safety and clinical efficacy of mini-open retroperitoneal oblique lumbar interbody fusion (OLIF) for the treatment of lumbar spinal tuberculosis.

METHODS

A total of 115 patients who suffered from lumbar spinal tuberculosis from June 2014 to December 2017 were included in this research. A total of 59 patients underwent OLIF and percutaneous pedicle screw fixation (OLIF group) and 56 patients underwent the anterior-only approach (anterior-only group). All patients were followed up for at least 24 months. Operation time, blood loss, and rate of complications were used to assess the safety of these two techniques. The visual analog scale (VAS) and the Oswestry disability index (ODI) were used to evaluate the relief of neurological and functional symptoms. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured to investigate the activity and recurrence of spinal tuberculosis. The Cobb angle, the sagittal vertical axis of the spine (SVA), the pelvic tilt (PT), the sacral slope (SS), the pelvic incidence (PI), and postoperative Frankel classification were also used to assess the efficiency of the spine deformity correction and the recovery of long-term neurological function.

RESULTS

Most patients were successfully treated with OLIF and the anterior-only technique and attained satisfactory clinical efficiency during the 24-month follow-up period. In the perioperative period, the mean operative time (154.68 ± 23.64 min, P < 0.001), the mean blood loss (110.57 ± 87.67 mL, P < 0.001), and the mean hospital stay (9.55 ± 3.62 days, P < 0.001) of the OLIF group were all significantly lower than in the anterior-only group (172.49 ± 25.67 min, 458.56 ± 114.89 mL, and 14.89 ± 3.89 days, respectively). A total of 10 patients (16.95%) experienced complications in the OLIF group, including neurological injury, segmental artery and iliac vein lacerations, peritoneal injury, instrument failure, and infection of incisions; this rate of complications was lower than in the anterior-only group (37.50%, P = 0.013). Regard to spinal deformity correction, the Cobb angle (9.42° ± 1.72°, P = 0.032), the SVA (2.23 ± 1.07 cm, P = 0.041), the PT (14.26° ± 2.37°, P = 0.037), and the SS (39.49° ± 2.17°, P = 0.042) of the OLIF group at last follow-up were all significantly different when compared to the anterior-only group (14.75° ± 2.13°, 3.48 ± 0.76 cm, 18.58° ± 1.45°, and 36.78° ± 1.96°, respectively). The VAS and the ODI of the OLIF group at 1 week postoperatively (3.15 ± 0.48, 21.85 ± 3.78, P = 0.032, 0.037) and at the last follow-up (2.12 ± 0.35, 16.70 ± 5.25, P = 0.043, 0.035) were both lower than for the anterior-only group (5.18 ± 0.56, 29.83 ± 5.42 and 3.67 ± 0.62, 20.68 ± 6.23). The Frankel classification was improved for both OLIF and anterior-only patients; however, there were 35 cases (59.32%) classified as Frankel grade E in the OLIF group and 22 cases (39.29%, P = 0.021) in the anterior-only group CONCLUSION: The OLIF surgical technique for single lumbar (L₂ -L₅ ) spinal tuberculosis is less invasive, has lower complication rates, and is more efficient than the anterior-only approach. However, the long-term effects of this surgical technique still need to be explored.

Early surgical intervention for active thoracic spinal tuberculosis patients with paraparesis and paraplegia

Background

To explore the therapeutic effect of early surgical intervention for active thoracic spinal tuberculosis (TB) patients with paraparesis and paraplegia.

Methods

Data on 118 active thoracic spinal TB patients with paraparesis and paraplegia who had undergone surgery at an early stage (within three weeks of paraparesis and paraplegia) from January 2008 to December 2014 were retrospectively analyzed. The operation duration, blood loss, perioperative complication rate, VAS score, ASIA grade and NASCIS score of neurological status rating, Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), kyphotic Cobb’s angle, and duration of bone graft fusion were analyzed to evaluate the therapeutic effects of surgery.

Results

The mean operating time was 194.2 minutes, and the mean blood loss was 871.2 ml. The perioperative complication rate was 5.9 %. The mean preoperative VAS score was 5.3, which significantly decreased to 3.2 after the operation and continued decreasing to 1.1 at follow up (P<0.05). All cases achieved an increase of at least one ASIA grade after operation. The rate of full neurological recovery for paraplegia (ASIA grade A and B) was 18.0 % and was significantly lower than the rate (100 %) for paraparesis (ASIA grade C and D) (P<0.05). On the NASCIS scale, the difference in the neurological improvement rate between paraplegia (22.2 % ± 14.1 % in sensation and 52.2 % ± 25.8 % in movement) and paraparesis (26.7 % ± 7.5 % in sensation and 59.4 % ± 7.3 % in movement) was remarkable (P<0.05). Mean preoperative ESR and CRP were 73.1 mm /h and 82.4 mg/L, respectively, which showed a significant increase after operation (P>0.05), then gradually decreased to 11.5 ± 1.8 mm/h and 2.6 ± 0.82 mg/L, respectively, at final follow up (P<0.05). The mean preoperative kyphotic Cobb’s angle was 21.9º, which significantly decreased to 6.5º after operation (P<0.05) while kyphotic correction was not lost during follow up (P>0.05). The mean duration of bone graft fusion was 8.6 ± 1.3 months.

Conclusions

Early surgical intervention may be beneficial for active thoracic spinal TB patients with paraparesis and paraplegia, with surgical intervention being more beneficial for recovery from paraparesis than paraplegia.

Proteomic analysis reveals critical molecular mechanisms involved in the macrophage anti-spinal tuberculosis process

Tuberculosis infection activates the autoimmune system. However, the role of host-pathogen interactions involved in Mycobacterium tuberculosis infection is unclear. In this study, we analyzed 6 spinal tuberculosis tissues and 6 herniated disc tissues by using liquid chromatography-tandem mass spectrometry coupled with tandem mass spectrometry, and immunohistochemical staining was performed for validating the results. We identified 42 differential immune-related proteins and 3 hub genes that are primarily localised in the tertiary granule and involved in biological processes such as cellular response to the presence of cadmium ions, regulation of ion transmembrane transport, transmembrane transport, and inflammatory responses. Genes encoding cytochrome B-245 beta chain (CYBB), matrix metallopeptidase 9 (MMP9), and C-X-C motif chemokine ligand 10 (CXCL10) were identified as the hub genes that exhibited anti-tuberculosis activity and were responsible for macrophage resistance against M. tuberculosis. In conclusion, CYBB, MMP9, and CXCL10 resist M. tuberculosis infection through chemotaxis and macrophage activation. Our results indicate that CYBB, MMP9, and CXCL10 could be considered as molecular targets for spinal tuberculosis treatment, which may significantly improve patients' quality of life and prognosis.

Spinal Tuberculosis Treatment: An Enduring Bone of Contention

Spinal tuberculosis is the most common form of extrapulmonary tuberculosis. It is of great importance to neurologists because of the potentially devastating complication of paraplegia, which may set in during active disease or the healed phase. Due to the deep-seated nature of the disease, definitive diagnosis is often challenging. There is no clear consensus on the appropriate duration of therapy for spinal tuberculosis, with various guidelines recommending treatment from as short as 6 months to up to 18 months. In this article, we present a critical appraisal of the evidence on the same. In our opinion, the duration of antitubercular therapy needs to be individualized and the decision to terminate therapy should be multifactorial (clinical, radiological, pathological/microbiological where possible) rather than being enmeshed within any particular guideline.

Anterior debridement, decompression, fusion and instrumentation for lower cervical spine tuberculosis

BACKGROUND

Antituberculosis chemotherapy have been widely used for lower cervical spine tuberculosis and brought out favorable outcomes. However, the contribution of surgical treatment is not well investigated yet. Therefore, this study aimed to evaluate the clinical efficacy and feasibility of surgical treatment for lower cervical spine tuberculosis by anterior debridement, decompression, fusion and instrumentation.

METHODS

From April 2011 to July 2016, 17 patients (9 males and 8 females, average age, 45.7 ± 16.8 years) with lower cervical spine tuberculosis (C4-C7) underwent anterior debridement, decompression, fusion and instrumentation. Frankel grading and visual analogue scale were used to assess neurological function and neck pain, respectively. Operating time, blood loss, erythrocyte sedimentation rate, C-reactive protein, kyphosis angle and postoperative complications were used to evaluate the clinical outcomes of surgery.

RESULTS

The surgery duration time range from 78 to 322 min (average 136.2 ± 61.1 min) and the blood loss range from 50 to 500 ml (average 127.7 ± 110.9 ml). Kyphosis angle was 10.8 ± 11.8°on average preoperative and returned to -6.3 ± 10.4° postoperative (P < 0.001, t = 12.3) and remained -4.4 ± 9.9°at final follow-up (P < 0.001, t = 11.8). The average preoperative and final follow-up visual analogue scale scores were 4.6 ± 1.3 and 0.6 ± 0.5 respectively (P < 0.001, t = 13.5). The erythrocyte sedimentation rate and C-reactive protein decreased gradually postoperative and returned to normal at final follow-up. No postoperative severe complications and no recurrence of tuberculosis occurred in all cases and neurologic function was improved in various degrees.

CONCLUSION

Anterior debridement, decompression, fusion and instrumentation could serve as an effective treatment in the management of the lower cervical spine tuberculosis.

Challenges and controversies in the treatment of spinal tuberculosis

Current guidelines regarding management of spinal TB are mostly extrapolated from trials on pulmonary disease. Since the British Medical Research Council (BMRC) trials in the 1970s, there are not many good quality studies that substantiate best practice guidelines for the management of this entity. Tuberculous infection of the spine behaves much differently from bacterial osteomyelitis and limited data leads to ambiguity in many cases. Although a few studies have been conducted in patients with spinal TB, most were in the era preceding short course chemotherapy and prior to current radiological and surgical advances. While spinal TB is primarily managed medically, surgical intervention may be needed in certain cases. We discuss areas of uncertainty and challenges that exist with regards to medical treatment, diagnosis, therapeutic endpoints, and a few surgical considerations. Substantial delay in diagnosis continues to be common with this disease even in the developed nations, leading to substantial morbidity. In light of limited evidence, there is an emerging recognition of the need to individualize various aspects of its treatment such as duration, frequency and acknowledging the limitations of various diagnostic and radiological modalities. We aim to consolidate potential areas of research in the diagnosis and management of spinal TB and to revisit the latest published evidence on its redressal.

Unilateral or Bilateral Percutaneous Endoscopic Debridement and Lavage Treatment for Lumbar Spinal Tuberculosis

OBJECTIVE

To compare the clinical outcome between bilateral percutaneous endoscopic debridement and lavage (PEDL) and unilateral PEDL treatment for lumbar spine tuberculosis (LST).

METHODS

A total of 40 patients with LST who underwent either bilateral PEDL (group A) or unilateral PEDL (group B) were reviewed. Perioperative parameters were assessed by operative time, intraoperative fluoroscopy times, and days of postoperative continuous irrigation and vacuum drainage. Clinical outcomes were evaluated in the Oswestry Disability Index (ODI), visual analog scale (VAS), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). All patients were followed-up for at least 18 months after treatment.

RESULTS

The average operative time and intraoperative fluoroscopy time were increased in group A compared with those in group B. There was no statistical significance between the 2 groups in postoperative continuous irrigation and vacuum drainage days. The ESR and CRP curves in the 2 groups showed a similar trend during 18-month follow-up. The VAS and ODI in the 2 groups significantly decreased 6 and 18 months postsurgery. There was no significant difference in the incidence of complication between the 2 groups.

CONCLUSIONS

Two procedures yielded comparable and satisfactory results. Unilateral PEDL showed shorter operative time and decreased intraoperative fluoroscopy times compared with bilateral PEDL. We suggest the use of unilateral PEDL rather than bilateral PEDL in the treatment of LST.

Treatment of Drug-Susceptible Tuberculosis

Mycobacterium tuberculosis is a major public health concern and requires prompt treatment. Goals of treatment include curing the individual patient and protecting the community from ongoing tuberculosis transmission. To achieve durable cure, regimens must include multiple agents given concurrently and in a manner to ensure completion of therapy. This article focuses on preferred regimens of drug-susceptible tuberculosis under current guidelines by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America and World Health Organization. In addition, topics including patient centered care, poor treatment outcomes, and adverse effects are also discussed.

Multi-drug resistant spinal tuberculosis-epidemiological characteristics of in-patients: a multicentre retrospective study

Tuberculosis (TB) is the leading cause of death among infectious diseases. China has a high burden of TB and accounted for almost 13% of the world's cases of multi-drug resistant (MDR) TB. Spinal TB is one reason for the resurgence of TB in China. Few large case studies of MDR spinal TB in China have been conducted. The aim of this research was to observe the epidemiological characteristics of inpatients with MDR spinal TB in six provinces and cities of China from 1999–2015. This is a multicentre retrospective observational study. Patients' information was collected from the control disease centre and infectious disease database of hospitals in six provinces and cities in China. A total of 3137 patients with spinal TB and 272 patients with MDR spinal TB were analysed. The result showed that MDR spinal TB remains a public health concern and commonly affects patients 15–30 years of age (34.19%). The most common lesions involved the thoracolumbar spine (35.66%). Local pain was the most common symptom (98.53%). Logistic analysis showed that for spinal TB patients, reside in rural district (OR 1.79), advanced in years (OR 1.92) and high education degree (OR 2.22) were independent risk factors for the development of MDR spinal TB. Women were associated with a lower risk of MDR spinal TB (OR 0.48). The most common first-line and second-line resistant drug was isoniazid (68.75%) and levofloxacin (29.04%), respectively. The use of molecular diagnosis resulted in noteworthy clinical advances, including earlier initiation of MDR spinal TB treatment, improved infection control and better clinical outcome. Chemotherapy and surgery can yield satisfactory outcomes with timely diagnosis and long-term treatment. These results enable a better understanding of the MDR spinal TB in China among the general public.

Spinal tuberculosis: a comprehensive review for the modern spine surgeon

Nearly one-third of the human population is infected with tuberculosis. Of those with active disease, approximately 10% are impacted by skeletal tuberculosis. Though, traditionally a disease of the developing world and susceptible populations, with the rise of immigration, patients may present in developed countries. The microbe responsible is the mycobacterium tuberculosis complex bacillus. The infection begins in the anterior vertebral bodies. The natural history and presentation are notable for cold abscesses causing mass effect, early or late neurological deficit, and kyphotic deformity of the spine caused by anterior vertebral body destruction. The disease can be diagnosed with laboratory studies and characteristic imaging findings, but tissue diagnosis with cultures, histology, and polymerase chain reaction is the gold standard. The cornerstone of medical management is multidrug chemotherapy to minimize relapse and drug resistance, and can be curative for spinal tuberculosis with minimal residual kyphosis. Surgical management is reserved for patients presenting with neurological deficits or severe kyphosis. The mainstays of surgical management are debridement, correction of spinal deformity and stable fusion. With appropriate and timely management, clinical outcomes of the treatment of spinal tuberculosis are overall excellent.

Role of Additional Coronal Magnetic Resonance Imaging in Decompression and Reconstruction with or without Segment Salvage in Thoracic Spine Tuberculosis

Study Design

Retrospective and observational study.

Purpose

The present study aimed to develop guidelines for segment salvage or sacrifice based on the amount and status of the remnant portion of the vertebra as assessed by coronal magnetic resonance imaging (MRI) in addition to sagittal and axial images in thoracic spine tuberculosis (TB).

Overview of Literature

Indications for surgery have not changed significantly since the ‘middle path regimen’ was proposed by Tuli. Goals of modern surgical management of spinal TB include debridement of diseased vertebrae, spinal cord decompression, deformity correction, and spine stabilization. However, the extent of decompression has not been defined previously. Too less decompression will lead to compromised neurological recovery, whereas large extent of decompression is associated with increased surgical morbidity and longer segment to reconstruct.

Methods

Sixty-five patients with thoracic spine TB were divided into two groups (segment salvage/sacrifice) based on the thickness of the subchondral bone and endplate morphology of the vertebra as seen on MRI. The operative procedure in the form of instrumentation with Hartshill loop rectangle and sublaminar wire using the simultaneous anterior posterior approach in lateral position (versatile approach) was performed. The patients were analyzed for postoperative fusion, improvement in kyphosis angle, and followed up for development of complications.

Results

This method of deciding the level of fixation and segment salvage based on coronal MRI in addition to the sagittal and axial images provided good result in 64 of 65 patients, except for one patient in the segment sacrifice group who had graft buckling and resultant kyphosis.

Conclusions

For segment salvage, having a clear three-dimensional idea about the viable remnant bone is important. Viable salvaged segment reduces the morbidity of the procedure, length of the construct, and unnecessary debridement without compromising on the neural recovery and fusion rate. Hence, additional cone down coronal cuts must be required when MRI is suggestive for spinal TB because it will help in the decision making.

Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies

INTRODUCTION

Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies.

METHODOLOGY

We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups.

RESULTS

Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three.

CONCLUSION

Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.

Clinical Characteristics of 1378 Inpatients with Spinal Tuberculosis in General Hospitals in South-Central China

In this retrospective study, charts of inpatients with spinal tuberculosis (STB) treated in large-scale general hospitals in Changsha, Hunan, China, between 2007 and 2016 were reviewed to investigate their clinical characteristics. Demographic, epidemiological and clinical features, imaging findings, treatment methods, and prognosis were summarized and analyzed. There were 1378 patients, 805 males and 573 females, with a mean age of 43.7 years. The mean interval between symptom onset and diagnosis was 16.0 months (range 15 days-240 months). The incidence of back pain, radicular pain and symptoms of systemic toxicity was 92.5%, 40.1%, and 32.1%, respectively. The rate of neurological impairment was 49.9 %. STB was present in two or more vertebrae in 91.1% of patients, with two adjacent vertebrae being involved in 67.9% of them. The lumbar segment (38.2%) was the most frequently affected, followed by the thoracic spine (35.7%). The sacrococcygeal area was the least frequently involved (0.8%). Abscesses were detected in 65.5% of patients. One thousand patients (72.6%) were managed with surgery and 378 (27.4%) with anti-TB drugs only. Cure was achieved in 1215 patients (88.2%), whereas 49 (3.5 %) had relapses. Concomitant pulmonary TB (PTB) was diagnosed in 366 patients (26.6%) and 63 (4.6%) had concomitant diabetes. Compared with the previous five years, the number of older patients, urban patients, and medical staff with STB had increased by 6.1%, 5.2%, and 1.3%, respectively in the five years studied. STB remains a severe public health problem that cannot be ignored. Most of the patients ignored early symptoms and therefore received untimely treatment. Thus, surveillance for and treatment of STB in South-central China requires strengthening. In addition to the current China-wide database of patients with PTB, a China-wide database of patients with STB should also be set up.

Analysis of Treatment and Prognosis of 863 Patients with Spinal Tuberculosis in Guizhou Province

The objective of this study was to investigate the treatment and prognosis of patients with spinal tuberculosis in Guizhou province. A total of 863 patients with spinal tuberculosis admitted to our hospital from 2006 to 2017 were included in this study. All patients underwent standardized quadruple antituberculosis treatment. Eighty patients were lost to follow-up due to a change of their contact information or noncompliance. A total of 783 patients completed the follow-up. The average follow-up period was 20.33 ± 8.77 months (range: 6 to 38 months). Among these patients, 145 patients underwent conservative treatment, while 638 patients underwent surgical treatment. All patients in the surgery group were treated with lesion removal, bone graft fusion, and internal fixation. Preoperative and postoperative standard quadruple antituberculosis treatment was administered. The clinical efficacy was evaluated according to erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), visual analogue scale (VAS), Cobb angle correction, neurological functional recovery, and interbody fusion with bone graft and tuberculosis outcome. A total of 608 patients achieved clinical cure. The symptoms, physical signs, blood tests and imaging findings were improved in 143 patients. Twenty patients showed refractory clinical symptoms, and 12 patients had local tuberculosis recurrence. Conservative and surgical treatments are the mainstream treatments for spinal tuberculosis. According to the patients' individual conditions, individualized treatments should be used to achieve good efficacy. Standardized antituberculosis treatment should be applied over the course of spinal tuberculosis.

The spectrum of tuberculosis of the spine in pediatric age group: a review

INTRODUCTION

Pediatric spinal tuberculosis is characterized by rapid bone destruction and carries the risk of rapid onset neurological deficits and severe deformity of the spine. Behavior of spinal deformity over time is affected by growth of spine. Owing to this dynamic behavior of pediatric spinal tuberculosis both in active phase and in healed phase, it presents with challenges which are quite different from adults with caries spine. A clinician must have high index of suspicion for accurate and early diagnosis of spinal tuberculosis in the pediatric population and should also have a thorough knowledge of differences in natural history between adult and pediatric spinal tuberculosis.

DISCUSSION

This is based on the senior author's experience of dealing with tuberculosis of the spine in children over the last two decades. Recent advances in field of rapid diagnosis of tuberculosis based on nuclear material-related diagnostic tests have further improved the management of tuberculosis. At the same time, the basic treatment principles remain the same. However, the threshold for surgical vs conservative treatment have subtle differences when compared to adult population. The importance of long-term follow-up after treatment must be appreciated.

CONCLUSION

Tuberculosis in the spine in children needs early attention. Prompting to diagnostic and medical therapy measures can avoid neurological sequellae and delayed deformity.

Spinal tuberculosis: review of current management

Tuberculosis (TB) remains endemic in many parts of the developing world and is increasingly seen in the developed world due to migration. A total of 1.3 million people die annually from the disease. Spinal TB is the most common musculoskeletal manifestation, affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some regions, adds to the burden and the complexity of management. This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV and both the medical and surgical options in the management of spinal TB. Cite this article: Bone Joint J 2018;100-B:425-31.

Spondylodiscitis revisited

Spondylodiscitis may involve the vertebral bodies, intervertebral discs, paravertebral structures and spinal canal, with potentially high morbidity and mortality rates.

A rise in the susceptible population and improved diagnosis have increased the reported incidence of the disease in recent years.

Blood cultures, appropriate imaging and biopsy are essential for diagnosis and treatment.

Most patients are successfully treated by conservative means; however, some patients may require surgical treatment.

Surgical indications include doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain.

Cite this article: EFORT Open Rev 2017;2:447–461. DOI: 10.1302/2058-5241.2.160062

Tuberculosis of the spine with severe angular kyphosis

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Patients and Methods

This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed.

Results

All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97° to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years).

Conclusion

Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. Cite this article: Bone Joint J 2017;99-B:1381–8.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Back pain and oedematous Schmorl node: a diagnostic dilemma

A 26-year-old female from India presented with progressive, unremitting low back pain for over 1 year. She had been treated unsuccessfully for left-sided sacroiliitis, pelvic floor dysfunction, ankylosing spondylitis and seronegative spondyloarthritis. MRI lumbar spine showed a Schmorl node with surrounding marrow oedema at L4, the relevance of which is not clear in literature. One year after initial presentation, a biopsy of this lesion revealed culture positive diagnosis of spinal tuberculosis. Despite advances in imaging, delayed diagnosis is not uncommon in spinal tuberculosis (TB). In our case, it was also attributed to an unknown early lesion: Schmorl node with surrounding oedema. Any association of this lesion with spinal TB has previously not been reported.

A novel indication for a method in the treatment of lumbar tuberculosis through minimally invasive extreme lateral interbody fusion (XLIF) in combination with percutaneous pedicle screws fixation in an elderly patient: A case report

RATIONALE

To describe a novel indication for a method through minimally invasive extreme lateral interbody fusion (XLIF) in combination with percutaneous pedicle screwsfixation in the treatment of lumbar tuberculosis (TB) in an elderly patient, and its clinical efficacy and feasibility. Lumbar TB is a destructive form of TB. Antituberculous treatment should be started as early as possible. In some circumstances, however, surgical debridement with or without stabilization of the spine appears to be beneficial and may be recommended. Surgeries through the approach of anterior or posterior are still challenging and often involve some complications.

PATIENT CONCERNS

The case is a 68-year-old female who was misdiagnosed as simple vertebral compression fracture and underwent L1 and L2 percutaneous vertebroplasty in another hospital 7 years ago. He complained of lumbosacral pain for 1 month this time. Magnetic resonance imaging (MRI) and computed tomography (CT) showed intervertebral space in L1/2 was seriously damaged like TB.

DIAGNOSES

Lumbar tuberculosis INTERVENTIONS:: Antitubercular drugs, mini-invasive debridement with XLIF in combination with percutaneous pedicle screwsfixation was performed. This patient was followed up for 12 months.

OUTCOMES

No obvious complication occurred during the operation and the wound healed well. Oswestry Disability Index (ODI: 56 vs 22) and visual analog scale (VAS: 4 vs 0) score significantly decreased atfinal follow-up of 12 months. Obvious recovery of kyphosis angle was found postoperatively (post: 14.8° vs pre: 33.5°). No recurrent infection occurred at the last follow-up.

LESSONS

Mini-invasive surgery by debridement through XLIF and percutaneous pedicle screwsfixation may be an effective and innovative treatment method for lumbar TB in the elderly.

Early diagnosis of spinal tuberculosis

Spinal tuberculosis (STB) is a common manifestation of extrapulmonary tuberculosis (TB). STB accounts for around 2% of all cases of TB and around 15% of extrapulmonary TB cases. The World Health Organization has proposed a global strategy and targets for TB prevention, care, and control after 2015. Under this strategy, patients will receive standard care according to the recommendations and guidelines after confirmation of STB diagnosis. However, current recommendations and guidelines focus on disease and medication therapy management, and recommendations for early detection or decision-making algorithms regarding STB are lacking. In this review, we identified five key components for early diagnosis: (1) risk factors for STB; (2) common symptoms/signs of STB; (3) significant neuroradiological findings of STB; (4) significant laboratory findings of STB, including positive interferon-γ release assays and nonpyogenic evidence in initial laboratory data; and (5) significant clinical findings of STB. Individualized consideration for each patient with STB is essential, and we hope that the algorithm established in this review will provide a valuable tool for physicians who encounter cases of STB.

Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis

PURPOSE

Whether radical debridement is necessary for the treatment of thoracic and lumbar tuberculosis is still questionable. The objective of this prospective randomized study was to compare the outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar tuberculosis.

METHODS

Seventy-four thoracic and lumbar tuberculosis patients with a neurological function of grade D and E underwent surgery and received the same chemotherapy regiment from January 2009 to October 2014. All patients were divided into group A and B by taking the drawing of lots. In group A, radical debridement, bone graft, and instrumentation were performed. Isolated posterior instrumentation without debridement were performed in group B. The operative time, blood loss, visual analogue score (VAS), erythrocyte sedimentation rate (ESR), kyphotic angle, Frankel grading, fusion rate, and complications were evaluated.

RESULTS

Group B had a better clinical outcome with regard to the operative time, blood loss, VAS score first week post-operatively, and the ESR value in the third and sixth month post-operatively than group A, and the differences between the two groups about those values all presented a significant difference (P < 0.05). However, no difference was observed between the two groups for the kyphotic angle (P = 0.088) and fusion rate (P = 0.164) at the final follow-up. Neurological function of all cases exhibited normal neurological function in the two groups at the final follow-up. Two cases of pulmonary infection and four cases of wound infection in group A. No serious complications were observed in group B.

CONCLUSIONS

Isolated posterior instrumentation without debridement is a suitable treatment for selected patients because of minor surgical trauma, fewer complications, and spontaneous fusion.

The outcomes of chemotherapy only treatment on mild spinal tuberculosis

Background

The treatments for spinal tuberculosis (TB) patients without absolute surgical indications have been controversial. Some people believed that most spinal TB patients were indicated for surgery, while other people believed in chemotherapy only. To help clarify the treatment over spinal TB patients without absolute surgical indications, we characterized a subtype spinal TB and then analyzed the treatment outcomes of standard chemotherapy alone.

Methods

In this retrospective study, 740 adult patients of spinal TB from January 2005 to January 2013 in our institution were reviewed. Patients who fit into the characterizations of mild spinal TB were started by standard chemotherapy for 18 months and followed up for at least 2 years upon the completion of treatment. The overall outcome, neurological function, local kyphosis, and level of pain at different time points were assessed.

Results

After starting the conservative treatment, 89 out of 740 patients were chosen for chemotherapy alone, and all patients were followed up for at least 2 years (ranging from 24 to 50 months) upon the completion of the treatment. Of 89 patients, 95.4 % of patients showed a definite and clinical response within 1 month after starting the treatment, 69 % of patients had excellent to good results, with no complications of the disease, and 77.5 % had asymptomatic local kyphosis with intact neurological function; solid bony fusion of adjacent segment was achieved in 88.8 % of patients.

Conclusions

We believe that the mild spinal TB respond well to the standard chemotherapy, and the detailed description of mild TB would provide crucial guidance in determination of conservative treatment.

Use of Intramedullary K-Wire to Enhance Fibular Graft Placement in 4-Level Thoracolumbar Corpectomy for Pott Disease: Case Report and Review of Literature

BACKGROUND

Reports of tuberculosis involving ≥4 contiguous spinal levels are rare. Surgery is often required in this population for neurological decompression and stabilization. These patients appear to be particularly predisposed to complications that include incomplete recovery of neurological function after decompression as well as post-treatment kyphosis. In settings with limited available instrumentation, reconstruction of the anterior column can be challenging.

CASE DESCRIPTION

A 35-year-old woman presented with back pain, progressive weakness in her bilateral lower extremities, and inability to walk for 2 months. Imaging demonstrated anterior destruction of T10, T11, T12, and L1 with severe retropulsion and cord impingement at T11-T12. The patient was taken for anterolateral corpectomies of T10-L1 with decompression of the thoracic spinal cord and fibular strut autograft placement followed by a T8 to L3 posterior spinal fusion. An intramedullary Kirschner-wire (K-wire) was placed during the anterolateral procedure to enhance fibular graft placement and prevent dislodgement before definitive posterior fusion.

CONCLUSIONS

At follow-up five-and-a-half months after the operation, the patient had recovered full strength and was ambulating without difficulty. Imaging at this time demonstrated stable restoration of alignment without graft dislodgement. Intramedullary fibular K-wire placement in this procedure helped to optimize anterior column reconstruction. The principles used in this report may prove beneficial to surgeons in developing countries who encounter pathology of this extent.

The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Management of spinal tuberculosis: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis of randomized controlled trials (RCTs) studying the clinical benefit of chemotherapy with surgical intervention over chemotherapy alone for the treatment of spinal tuberculosis.

METHODS

Relevant RCTs were identified by computerized database searches. Trial eligibility and methodological quality were assessed and data were extracted and analysed using odds ratios with 95% confidence intervals. The primary outcome measure was kyphosis angle.

RESULTS

The literature search identified two RCTs conducted in the 1970s and 1980s and a Cochrane Database Systematic Review published in 2006. There were no significant between-group differences in kyphosis angle, bony fusion, bone loss or development of neurological deficit.

CONCLUSIONS

There is no obvious statistically significant clinical precedence to suggest that routine surgery will improve the prognosis of patients with spinal tuberculosis.

One-stage posterior surgical treatment for lumbosacral tuberculosis with major vertebral body loss and kyphosis

The treatment goals of tuberculous spondylitis are to eradicate infection and to prevent or treat instability, deformity, and neurologic deficit. The purpose of this study was to evaluate the clinical outcomes following chemotherapy with 1-stage posterior debridement, correction, and instrumentation and fusion for the treatment of lumbosacral tuberculosis with major vertebral body loss and kyphosis. Fourteen patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis underwent 1-stage posterior surgery. Clinical assessments included low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores, neurologic deficit, erythrocyte sedimentation rate, and C-reactive protein level. Radiographic parameters included kyphosis angle, anteroposterior translation, local scoliosis, lumbar lordosis, pelvic parameters, sagittal offset, and fusion. Thorough debridement was performed. Patients were followed for an average of 39.3 months. Constitutional symptoms, low back ache, and functional outcome improved in all patients postoperatively. At final follow-up, Frankel Grade improved by 0 to 2 grades, mean kyphosis angle improvement was 44.3°, and satisfactory spinopelvic and sagittal balance were achieved. Spinal posterolateral fusion was obtained in all patients and no fixation loosening was found at 2-year follow-up. Differences existed between the pre- and postoperative radiographic parameters (P<.05). Correction loss at last follow-up was not statistically significant (P>.05). No surgical complications or infection recurrence occurred. Tuberculosis can be cured and effective correction of kyphosis can be achieved for lumbosacral tuberculosis with major vertebral body loss and kyphosis by performing 1-stage posterior surgery and chemotherapy.